Executive summary

Registered home births

This is the tenth national clinical audit report on registered HSE home births in Ireland. The report provides details on the 387 women who were registered for a home birth from January 1st, 2023, to December 31st, 2023. Of these, 223 women gave birth at home. These equate to 0.7% and 0.4% of all women who gave birth in the country in 2023, respectively. Although a slight decline in registrations was noted in 2023, the rate remains high compared to the earlier years of the audit. Meanwhile, the percentage of women who ultimately give birth at home has declined over time, suggesting increasing transfer rates.

As seen in previous years, women aged 30 and 39 continue to be the most represented age group among those who registered for a home birth in 2023 (76.3%). The majority were of white Irish ethnicity (71.8%) and had a BMI within the healthy range (18.5–24.9 kg/m²; 62.5%). Women who had a previous birth represented a higher proportion of registrations than women who had not previously given birth (64% vs 36%, respectively). Almost 40% of women who had previously given birth had experienced a previous home birth (38.3%).

All the women registered for a home birth in 2023 also registered with a maternity hospital. The average distance of the woman’s residence to her community midwife was 28.2km, and the average distance from the hospital in which the woman was registered was 24.7kms. Almost two-thirds of women lived within 30kms from the maternity hospital (65.8%).

A specific liaison obstetrician was available for over half the women (51%), while a liaison clinic was available for a further 5%. Despite the majority of women registering with a general practitioner (GP), roughly 40% received full shared care. Midwifery-led hospital services were commonly used as an alternative to GP care.

In 2023, almost a quarter of women who registered for a home birth had at least one reported risk factor or pre-existing medical condition that required a review at booking (24.3%), the most common reason in 2023 continued to be a maternal age over 40 years. Among women with a previous pregnancy, 19.5% were reported to have had a previous obstetric condition or risk factor, the most commonly reported reason being a past history of group B streptococcus.

During the current pregnancy, 43% of women developed a medical or obstetric condition, many of the conditions fell into the category of “other” reflecting a wide range of clinical reasons. This was followed by prolonged rupture of membranes without signs of labour, experienced by approximately 16% of women. An obstetric review was required for the majority (91.7%) of women who developed a medical or obstetric condition during pregnancy, with the remainder appropriately managed within the community setting.

In total, 117 women required an antepartum transfer (30.2%), inclusive of women who required transfer after obstetric review, and also women who chose to transfer their care. In 2023, women who did not require an antepartum transfer and therefore continued their pregnancy under the care of the home birth service received a median of six antepartum visits from their midwife.

Of the 270 women who started labour at home under the care of the HSE Home Birth Service in 2023, almost 18% required an intrapartum transfer to hospital. As in previous years, nulliparous women were significantly more likely to transfer during labour than multiparous women, a nearly sevenfold difference (44.9% vs 6.8%). The primary reasons for transfer were confirmed delay in the first or second stage of labour (33.3%) and maternal request for medical analgesia (27.1%). For nearly four in five women, the decision to transfer occurred during the first stage of labour (79.2%). In 2023, the average duration of intrapartum transfers was 39.5 minutes.

Access to the birth records following antepartum or intrapartum transfer has vastly improved over the last 3 years, potentially an early reflection of the ongoing integration of the home birth service with the acute hospital services.

Women who gave birth at home and their infants

Of the women who gave birth at home in 2023, almost 95% were attended by their primary community midwife, with roughly 79% also having a second midwife present. The remainder gave birth before the arrival of the midwife. All fours and kneeling were the most common birth positions, used by 66% of women. Water immersion was the most frequently used pain relief option, availed of by 54% women, one fifth of whom went on to give birth in the water.

Physiological management of the third stage of labour was more common among women who gave birth home in 2023 (71%), compared to 29% who had active management. Nearly half of the women (43.5%) had an intact perineum following their home birth, with 26% experiencing a first-degree tear and 27.4% a second-degree tear. Third-degree tears and episiotomies remained rare. The mean estimated blood loss during home birth was 304ml.

Following the home birth, the average number of postpartum visits by community midwives was 5.3, with average day of discharge from the service being 11.7 days. A small number of women experienced a complication following the home birth (n=28), 15 of which were transferred to hospital. One further woman was transferred in with her infant, bringing the total to 16. The most common reason was extensive perineal tearing, accounting for 38% of all postpartum transfers.

Of the babies born at home in 2023, almost all had reassuring Apgar scores of 7-10 at one and five minutes after the birth (97.2%). No infant had a score below 7 at five minutes. A small number of babies required resuscitation (2.7%) with positive outcome. Less than 10% of babies required transfer to hospital after the birth (8.1%), the primary reason was to accompany the mother who required transfer (61%), followed by respiratory symptoms (17%).

The majority of babies received vitamin K (83.4%), mainly via intramuscular injection (72.6%). In 2023, of the women who gave birth at home, 93.7% were exclusively breastfeeding their infants at discharge from the service.

The perinatal mortality rate for all women who registered for a home birth from 2012 to 2023 was 2.91 perinatal deaths per 1,000 births, inclusive of women who were transferred in the antepartum and intrapartum periods. This rate was broadly similar to the equivalent rates among all births in 2023.

Of the adverse incidents that were identified, the majority were classified as Category 3 incidents, the most common reason being waterbirth, which were reported due to the HSE’s temporary pause on waterbirth in the home setting (in effect from November 2020 to December 2023).